Provider Demographics
NPI:1851335335
Name:MILLS-PENINSULA HEALTH SERVICES
Entity Type:Organization
Organization Name:MILLS-PENINSULA HEALTH SERVICES
Other - Org Name:MILLS DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP SHARED SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-297-8555
Mailing Address - Street 1:PO BOX 742738
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2738
Mailing Address - Country:US
Mailing Address - Phone:650-696-5400
Mailing Address - Fax:650-652-3052
Practice Address - Street 1:100 S SAN MATEO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3805
Practice Address - Country:US
Practice Address - Phone:650-696-5400
Practice Address - Fax:650-652-3052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA052340261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACDC03516FMedicaid
CACDC03516FMedicaid